Provider Demographics
NPI:1285521922
Name:JENESIS LIVING LLC
Entity type:Organization
Organization Name:JENESIS LIVING LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGING MEMBER
Authorized Official - Prefix:
Authorized Official - First Name:JACKLINE
Authorized Official - Middle Name:
Authorized Official - Last Name:MMBAGA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:269-285-3352
Mailing Address - Street 1:3403 AMANDA CT NW
Mailing Address - Street 2:
Mailing Address - City:CEDAR RAPIDS
Mailing Address - State:IA
Mailing Address - Zip Code:52405-1961
Mailing Address - Country:US
Mailing Address - Phone:269-999-0321
Mailing Address - Fax:
Practice Address - Street 1:3403 AMANDA CT NW
Practice Address - Street 2:
Practice Address - City:CEDAR RAPIDS
Practice Address - State:IA
Practice Address - Zip Code:52405-1961
Practice Address - Country:US
Practice Address - Phone:269-999-0321
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2025-06-23
Last Update Date:2025-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320600000XResidential Treatment FacilitiesResidential Treatment Facility, Intellectual and/or Developmental Disabilities